ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway.

BACKGROUND: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. METHODS: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P=0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. CONCLUSIONS: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. CLINICAL TRIAL REGISTRATION: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

Same-day discharge is feasible and safe in the majority of elderly patients undergoing elective percutaneous coronary intervention.

BACKGROUND: Same-day discharge after elective percutaneous coronary intervention (PCI) is safe in the majority of patients. However, the elderly have more comorbidities and less favorable coronary and peripheral arterial anatomy, which may preclude safe same-day discharge after PCI. We assessed the feasibility and safety of same-day discharge in an elderly cohort of patients. METHODS: A total of 1,580 consecutive patients undergoing elective PCI in a single center between January 2001 and January 2009 were included in the study. We compared the outcomes of elderly patients aged 75 or older to control patients under the age of 75 years. Patients were examined 6 hours post procedure and discharged if there were no complications. RESULTS: Of the 1,580 study patients 212 (13.4%) were elderly and 1,365 (86.6%) were younger controls. The elderly were more likely to be female, hypertensive and to have had previous coronary artery bypass graft (CABG) surgery and less likely to be smokers or to have hyperlipidemia (all p < 0.05). The number of lesions treated and their complexity were similar in both groups. Procedural success, in-hospital major adverse cardiac events (MACE) and the rates of same-day discharge were also similar in both groups. Same-day discharge was achieved in the majority (84%) of the elderly. There were no deaths within 24 hours of discharge. Readmission within 24 hours of discharge was rare (< 0.7%) in both groups. The 30-day MACE rate was low in both the elderly (3.3%) and control groups (3.6%; p = 1.0). CONCLUSIONS: Same-day discharge is safe and feasible in the majority of elderly patients following elective PCI.